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ethics

Poetry Book Review: The Wound Dresser

7 Sep, 16 | by cquigley

Two poetry book reviews will be featured this week. The second review will appear on Friday.

 

WoundDresser

 

Jack Coulehan, The Wound Dresser (Albuquerque: JB Stillwater, 2016)

Finalist for the 2016 Dorset Poetry Prize, selected by Robert Pinsky (Poet Laureate of the United States from 1997 to 2000).

Reviewed by Barbara Salas

 

The Wound Dresser by Jack Coulehan is a collection of 77 poems that explore the reality of being a physician, reflect on health and illness, and delve into the experience of suffering from different angles. In the following lines I will share how Coulehan’s poetry has made me reflect on diverse aspects of life, disease and on the art of medicine.

The book is the author’s sixth collection of poems, and its title alludes to a composition by Walt Whitman (whose photo appears on the book’s cover): verses that speak about the care of wounded soldiers during the Civil War, and to which Coulehan dedicates his very first piece of the collection. This theme of looking after the sick is central to the author’s poetry.

The order of the poems, though not clearly stated, seems to reveal the passage of time: from the “The Secret of the Care”, which opens the first section exploring the feelings of a junior doctor, to the very last poem of the series, “Retrospective”, which is a reflection on forty years of medical practice. This subtle timeline is structured into four parts, each one orbiting around common themes.

The first section comprises poems that generally reflect on the doctor-patient relationship. A recurrent element of these compositions is the idea of the physician as the one who witnesses the inner secrets of the patient. In “Take Off Your Clothes” we are invited to think about the physical examination: the patient exposed and vulnerable, and the doctor as the one with access to the “narrative in [the patient’s] flesh” (p. 23). Physician and patient are “intimate companions” in a journey through the intricacies of the body, in which we appreciate compassion and loving care from the doctor, but also patent fear from the patient: a topic often conveyed in Coulehan’s poetry (e.g. “The Rule of Thirds”, pp. 26-7).

However, the relationship established between doctor and patient, though close, appears to be at the same time “detached”, perhaps because the access to those secrets does not necessary grant intimacy. In fact, it sometimes seems to signify the opposite, something like a “cold distance”. The four poems “A Lesson in Diagnosis” (pp.5-8) convey to me this tension between “union” and “separation”. The closeness is transmitted through the acknowledgement of the patient’s vulnerability during the clinical exam (“During the discussion/ she keeps trying without success/ to cover her nakedness with a sheet.” p. 7), but the distance is present in the detachment that the doctors demonstrate both in their use of language as well as in their actions (“He drags us to another case —/ this one, a supraclavicular mass./ No one stoops to pick up her glasses.” p. 6). It is clear that while the patient is embedded in pain and anguish, the doctor sees and identifies the problem from afar, without being part of it or experiencing it.

Some poems reflect on the process of learning to practice medicine, and the feelings and thoughts that the clinical encounter trigger in the physician. The need to pretend to be competent (“I palpated/ their abdomens, balloted their livers,/ and listened to respiratory crackles,/ while disguising the depth of my doubt/ with a kindly, but serious look.” p. 3), or the difficulty in interacting with some patients (“I was surprised to find/ how much I disliked some of the patients” p. 3) is present in “The Secret of the Care”, the first poem of the collection. This made me ponder on the physician as the one who has two identities that sometimes stand in tension: on the one hand, the “professional” side that actively cares for the patient; and on the other, his inner world full of thoughts, worries and prejudices that are often hidden in the consultation yet present in his mind.

Finally, the contrast between the patient’s inner life and the painful reality of being ill captured my attention in this section. “The Silk Robe” (pp. 16-7), offers a glimpse of the patient’s life beyond the clinical setting by underlying details like her “blue silk robe”, her “scent” or her “delicate gold chain”. What those details evoke sharply contrast with the reality of her medical condition: the “cultures”, the “catheter”, and the “bed rest” reminds us that she is sick. While reading this poem I thought about the clinical encounter, during which sometimes doctors interact with patients as if their whole being were only their disease. Those doctors sadly forget that the patient is first and foremost an individual; a human being with an inner life that has to be acknowledged and respected. These two dimensions (the person as patient and as individual) are beautifully captured in Coulehan’s literary work.

The second section conveys, through reflections on historical figures or events and mythical accounts, how medicine has changed through time. It also reflects on how human elements like prejudices, fears or beliefs can shape the interaction between doctors and patients, both in the past and today. “To the Heart of Lazar Riverius, Galenist Physician” (p. 40) presents the contrast between the current medical practice (one that operates without “faith” and in a somewhat “mechanical” fashion) and the medicine of the past, which used to embrace the spiritual dimension of the person more openly (“Today the surgeons shut you down,/ open, patch you, put in plastic —/ and not a single Sign of the Cross!”).

In “McGonigle’s Foot” (pp. 42-3) we see how a century and a half ago (1862) prejudices on identity and nationality shaped the medical practice: since the patient is “a foreigner, a drunk, and loud” [emphasis original] there is no need to anesthetize him. (In the notes [pp. 99ff.] we learn that the poem was based on the idea that surgeons back then only gave opiates and alcohol “selectively”). Although we could be tempted to think that this speaks of something that only occurred in the past, the poem reminded me of recent published research in the US, which proves that today black people are less likely to be prescribed opiates for pain management than their white counterparts.1

The third section is a compilation of reflections on the passage of time, on life, and on death. Those moments occur around the world, in places like Alaska, Alexandria, Kosovo, or Cambodia. There are poems on the horrors of war (“War Remnants Museum, Ho Chi Minh City” p. 56), on the passage of time (“Deliver Us From Evil”, pp. 64-5), and on the contrast between life and death: in “Cesium 137” (p. 68) we are presented with a scene in Brazil where the same substance that uncovers the “loveliness” of the children (“their loveliness aglow at last”) also causes their death. That substance is the radioactive isotope cesium 137, deadly toxic.

The tone of this section is sharp, direct and often painful, particularly for me the poem “Christmas in Kosovo” (p. 57), an account of the result of the war in the Balkans. The verses unfold the horror of the conflict with brutal clarity:

“One of the men was found in the courtyard,

decapitated, and so far his head

remains missing. Many had been shot

at close range, after the solider pricked them

with machetes and brass knuckles. Later,

the women were raped, and in some cases

their bones were broken.”

That strongly contrasts with the moment in which the poet is witnessing those horrors (soon after Christmas): a time of hope for the coming of Christ, to which Coulehan alludes through the reference to Isaiah’s “Prince of Peace” (Isa 9:6 “For a child has been born for us, a son given to us; authority rests upon his shoulders; and he is named Wonderful Counselor, Mighty God, Everlasting Father, Prince of Peace”). That strain between hopelessness and belief, so present in the poem, made me reflect on the very same tension that is often present when coping with a diagnosis of a life-threatening illness.

Finally, the fourth section comprises family memories and meditations on personal experiences. This change of perspective enables the reader to think about health and illness from different angles, gaining a richer and deeper understanding of topics previously considered in other poems. “Fever of Unknown Origin” (p. 79) speaks about the urge to find explanations to events that are often impossible to account for (“I hold to an old script/ that says calamities have reasons (…) Convenient nonsense,/ but sometimes true.”), and about the need to find a cause to gain control over the disease. With the narrator as the patient, the poem is a reflection on the fear of being seriously ill, and the threat that that constitutes to our somehow perceived “ordered” reality.

The exposure and vulnerability that often patients feel while being examined is a topic extensively covered by Coulehan from the perspective of the doctor, but in “Role Model” (pp. 80-1) this matter is beautifully explored from the view of the patient. The detached and factual discourse of the physician contrasts with the feelings of shame of the patient, who just wants to leave and hide away from the clinician: a need that perhaps we have all felt at some point when being exposed in front of a stranger.

Overall, The Wound Dresser is a fascinating journey that takes us through the complexities of life, illness and death; a journey during which the reader has the opportunity to reflect on the tension between the objectiveness that supports the clinical encounter, the doctor’s inner world, and the patient’s humanity, secrets, fears, needs and contradictions. The presentation of clinical encounters, the use of historical figures or events, the look at scenes around the world, and the account of personal memories that Coulehan brings us facilitate a contemplation of health and illness from interesting and varied perspectives, thus enriching the reader’s world and triggering meaningful meditations on the art of medicine.

 

References

  1. Goodnough A. Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder. The New York Times [Internet]. 2016 [cited 15 August 2016];. Available from: http://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?smid=fb-share&_r=0

 

Further Reading

Blackhall, Leslie J., “Cultural Diversity And Palliative Care”, in Chochinov, Harvey Max and William Breitbart (Eds.), Handbook of Psychiatry in Palliative Medicine, 2nd Edition (Oxford: Oxford University Press, 2009), pp. 186-201.

 

 

Book review: The Heart

21 Jul, 16 | by cquigley

heart

Maylis de Kerangal, The Heart. Translated by Sam Taylor. Farrar, Strauss and Giroux, US.

In the UK it is titled Mend the Living, translated by Jessica French, and published by MacLehose Press.

 

Reviewed by Elizabeth Glass, PhD student in Comparative Humanities, University of Louisville.

 

The Heart by Maylis de Kerangal tells the story of 24 hours in the life, and death, of twenty-year-old Simon Limbeau. The narrative includes snippets from the brief hours before a car wreck that ultimately takes Simon’s life, moving through to the aftermath of his death when his heart is transplanted into the recipient Claire Méjan.

At the beginning of The Heart, Simon goes on a surfing trip with friends. On the way home, they are involved in a car accident. The other two young men escape with minor injuries, but Simon is critically injured. Once it has been determined that Simon’s injuries are fatal, and that his brain has ceased functioning, the doctor, Pierre Révol, approaches Simon’s parents to discuss organ donation. Initially reluctant, particularly about donating Simon’s heart which they believe holds his dreams, love and life, they eventually agree. Thereafter we follow the journey of Simon’s heart.

The Heart spends more time with Révol than any other character as we observe him negotiating with different aspects of the organ donation process. We also see Simon’s mom, Marianne, arrive at the hospital, her trauma heightened by being unable initially to get hold of her estranged husband, Sean, Simon’s dad. We then follow the interaction between the parents throughout the horrendous process of losing their adult son. We watch the hospital staff work with and around Simon. We are there when Révol asks Marianne and Sean to donate Simon’s organs. The most painful part of the novel involves witnessing Marianne’s reactions to learning new information about Simon as he is dying. Though we spend more time with Révol, we know Marianne better–we can feel her emotions. We meet Claire, who receives Simon’s heart. We also meet the transplant team and witness both operations: the organ removal surgery and the heart transplantation.

The novel is not about Simon’s life, and it is also not entirely about his death. Instead, it focuses on the donation and transplantation of Simon’s organs, and his heart in particular which we follow to Claire. We care about Simon’s organs as he is being kept alive awaiting surgery, and then it our own hearts that quicken as his is removed. The surgical scenes are the most tense in the novel overall. They allow the reader to alternate between a distance of watching from afar and that of being almost so near to hand that we could imagine ourselves passing the sponge to the surgeon. This is when we are closest to feeling and understanding what the characters experiencing. While the surgery and the donation process are both simplified, for someone who is only peripherally acquainted with such processes, the medical procedures were described in a detailed and interesting manner without becoming overly technical.

The Heart is told from an omniscient narrator’s point of view with a distance that gave me the feeling of being outside a glass door, or looking down from above in an operating theatre, an onlooker on unfolding scenarios. The narrator is not only all-knowing but is also an I who addresses the reader as you on occasion. This had the effect of taking me out of the moment of the action and of detaching me from the story. It caused me to wonder who I actually was, but the answer to this is never revealed and the identity of I remained hidden throughout. At one point the narrator writes, “You undoubtedly remember the description of the books on Révol’s metal shelf, mentioning a copy of an issue of that magazine from 1959, so you will have already guessed that the article appeared in that very issue” (p. 32). Instead of drawing me into the story, this aside had the opposite effect. Such asides were infrequent, but when they did occur I found them distracting. The narrator was not a presence that I was aware of all the time; the opposite in fact, as most of the time the narrator was in the background. Thus, when he or she appeared, it felt strange and distanced me from the ongoing story.

This distancing, which creates the illusion of watching what is happening, of being an onlooker instead of being directly involved, means that as readers we can only access the characters’ thoughts tangentially. The things we know are told to us, but with the impassivity of overhearing a stranger’s order at a restaurant. As a result, it is hard to care about the characters to the extent that the subject matter deserves. However, if one did become very involved with the serious content, The Heart would surely become a challenging and potentially harrowing read. Thus, the sense of clinical detachment evoked probably serves a useful purpose, and will, I suspect, ensure a wider readership.

Each sentence in The Heart tends to be a paragraph in length, containing many phrases separated by commas. This makes the novel a difficult read at times and is potentially distracting; yet it also encourages a sense of urgency. The reading experience felt halting initially, but this sensation ceased as I progressed through the book. At the outset I found myself stumbling and searching for parts of speech to make sense of some of the sentences, but there came a point later in the book when I found myself unable to put it down.

There are two versions of the novel translated into English from the original French: for the United States it is titled The Heart, and for the United Kingdom Mend the Living, which is a more direct translation of Maylis de Kerangal’s original French title Réparer les vivants. Mend the Living was nominated for the Man Booker Prize. The US reader will have difficulty with Mend the Living, however. For example, in Mend the Living, as Simon and his friends are getting ready to surf, they are said to have “liquid rhinitis, sleep with your clothes on.” In The Heart, it says they have, “runny noses, slept-in clothes.” This type of difference exists between the two translations throughout. The end of Mend the Living is as exciting as The Heart, but elements of the writing will limit its appeal to the American reader. Thus, for this reader, Sam Taylor’s translation was a more satisfactory read.

In terms of the Medical Humanities, The Heart is an illustrative example of the arts interacting with medicine. The reader witnesses doctors wrestling with complex ethical issues such as how far to push the parents to donate Simon’s organs, decisions around to whom his organs will be donated, as well as the reality of the organ removal surgery that ends his life. The reader also observes Claire’s Méjan’s difficulty coping with the fact of receiving the heart of someone who has died, as well as her transplant surgery. All these issues render The Heart a compelling read.

Overall, The Heart is a gripping novel. Although we know at the outset that Simon will die, this fact does not detract from the extent to wish it engages the reader. The book is not without its faults. The reading experience may indeed have benefitted from a shorter sentence structure, and from a more in depth delving into the characters’ minds and thoughts. Notwithstanding, the narrative that underpins the novel remains intriguing and engaging. The Heart is particularly recommended to readers of Medical Humanities.

 

 

 

Related reading

M Shildrick, P McKeever, S Abbey, J Poole and H Ross. Troubling dimensions of heart transplantation. Med Humanities 2009;35:1 3538

TA Faunce. Book review: Cutting for Stone. Med Humanities 2009;35:2 123124

Ayesha Ahmad: Introduction to Global Humanities—Through Creation, Violence Will Die

15 Mar, 16 | by Ayesha Ahmad

Against the backdrop of violence, I have been examining through my research the qualities of our human condition that perpetuate both our survival and our spirit.

As an introduction to an ongoing series on Global Humanities, I will be discussing ways we can counter the dominant narrative of violence.

Our globalised world, or rather, the collective ‘Other’, is met through encounters from suffering—the patients that enter our clinical settings, the individuals that sacrifice their lives to reach the shores of safety, and the images that we only ever see from afar of stories that breathe suffering.

more…

The Reading Room: Erik Parens’ ‘Shaping Our Selves…’ reviewed

1 Dec, 15 | by cquigley

 

Shaping Our Selves: On Technology, Flourishing and a Habit of Thinking by Erik Parens. Oxford University Press. 2014. xi+200 pages. Hbk. ISBN: 9780190211745.

Reviewed by Nathan Emmerich, Visiting Research Fellow, Queen’s University Belfast.

 

On the face of it Shaping Our Selves is about the way biomedical technologies, such as neurochemical enhancements and reconstructive surgeries, can be sued to alter and mould the human body and mind. However, the author has previously addressed both of these topics. What is on offer here is, first, a consideration of the way the ethical analysis of these technologies are characterised by polarised positions and, second, an account of binocularity. This latter is a metaphor and names a habit of thinking that, if adopted more generally, purports to promote a greater degree of mutual understanding between different sides in these debates.

Parens’ strategy is to demonstrate that participants in these debates do not simply disagree but have differing intellectual orientations, or lenses, through which they consider the matters at hand. Such disagreements are, therefore, a result of a fundamental incompatibility, even incommensurability, that lies at the heart of opposed ethical perspectives. Parens proposes that if we wish to increase our understanding of the matters at hand we should attempt to consider them by thinking in a binocular, as opposed to monocular, manner. Whilst he thinks that in the final analysis, and when deciding to act, we must lapse into monocularity (p.158), he maintains that when trying to fully understand the issues we can and must oscillate between different ‘lenses’ if we want to fully comprehend the issues at hand.

The binocular metaphor works because Parens is able to divide bioethics – or, at least, the literature on the topics he discusses – into two opposing and mutually incompatible camps each of which adopts different stances on a variety of matters. The camps are those of the enthusiasts and the critics. Those who inhabit these camps have, he says, two different kinds of ethical stances, each of which is associated with two different sets of conceptual ‘lenses.’ When he suggests binocularity involves oscillating between different perspectives it is these conceptual lenses he has in mind. This endeavour can be compared to the way our vision flips between seeing a duck and a rabbit in Wittgenstein’s famous example (p.39).

Thus, the purpose of binocularity is not to help us to see further and with greater clarity or to see in greater depth, at least not insofar as seeing in greater depth means developing a more detailed appreciation for the dimensions of a ‘monocular,’ ‘singular’ or ‘unified’ ethical picture. Rather it names a habit of thinking about different, mutually incompatible approaches to ethical arguments. The aim is not to adjudicate the arguments, to effect some kind of reconciliation or to uncover some sort of ‘third way’ compromise – although, particularly when one begins to think about substantive policy, this latter may in fact result. The avowed aim is, instead, to sensitise us to our own ethical partiality and, in so doing, to encourage us to become less combative and more bipartisan in our thinking. It is Parens’ hope that we will become less rigid in maintaining our ethical stances and, in so doing, become less concerned with winning ethical arguments and more concerned with developing a greater understanding of the issues.

It is a laudable aim and Parens’ discussion contains a great deal of insight into and appreciation for the essentially political problem of engaging in contemporary ethical debate in a mutually respectful manner. Nevertheless, there are some questions to be answered. For example, Parens divides bioethicists into enthusiasts and critics, roughly those who embrace emerging biotechnologies and those who are more cautious and critical of its potential impact. The characteristic perspectives of these two groups is fleshed out by a series of conceptual binaries, one of which is the idea that enthusiasts see biotechnology as ‘value-free’ whilst critics see it as ‘value laden’ (Chap. 4). Whilst this might be true of bioethicists like Julian Savulescu and John Harris, it is not clear that this applies to others who are positioned in this camp, such as James Hughes (p.60 & 95), Andy Clark (p. 81) and Donna Haraway (p.81). Indeed it is also not clear that these latter techno-enthusiasts – and other comparable figures such as, for example, Steve Fuller – would have much sympathy for the relative simplicity of utilitarian accounts. Equally, one could suggest that utilitarian bioethicists would no doubt find Haraway’s or Fuller’s thinking needlessly complex.

One can make a similar point about those who adopt a more critical stance. In Parens view the inhabitants of this camp include outright bio-conservatives such as Leon Kass (p.51), as well as more moderate conservatives such as Dan Callahan (p.15), Michael Sandel (p.60), and Hans Jonas (p.67). However, it also includes many if not most, sociologically inclined bioethicists such as Illina Singh (p.58), Jackie Leach Scully (p.136), and Tom Shakespeare (p.136), none of whom could really be considered anything but liberal in their general outlook. Whilst one might take this as suggesting there is a distinct problem with Parens binary nomenclature, it is important to note that he rejects the idea that the enthusiasts and the critics map onto standard political divisions of progressive liberals and traditional bio-conservatives (p.52).

Given the evident and significant differences between the perspectives held by those Parens groups into enthusiast and critic, we might consider Steve Fuller’s recent suggestion that the notions of left wing and right wing are undergoing an ‘axial rotation.’ Fuller’s thinking indicates that we should reframe these basic political differences in terms of ‘up wing’ and ‘down wing.’ The latter is associated with the ‘precautionary principle,’ something often espoused by those Parens has termed critics. In contrast the ‘up wingers’ are associated with the ‘proactionary principle’ or ‘imperative,’ an idea that stems from the enthusiasts’ reaction to the precautionary principle. Whilst they come from very different perspectives, Parens (the critic) and Fuller (the enthusiast) have, it seems, independently divided the world in very similar manners, indicating that their ideas have some degree of validity.

Whilst Parens’ division of bioethicists, and those who labour in associated fields, into enthusiasts and critics stands up to scrutiny, some of the associated binaries seem less robust. For example, he holds that enthusiasts see technology as value-free whilst critics hold that it is inherently value-laden (chap. 4). However, even if these individuals are not bioethicists per se, this division can be supported when we consider enthusiasts like Haraway, Clark and Fuller. Furthermore, given the scope of this division, what might it mean to propose that we oscillate between the view that our techno-scientific achievements are value-free and the view that they are value-laden? Parens asserts that “no thoughtful person would want to choose between thinking that technology is value-free and thinking it is value-laden” (p.93). Whilst I am not a true Scotsman, I certainly aim to be a thoughtful person and, as such, I fail to see why one should not ‘choose’ or, rather, conclude that all human technology is value-laden. In my view the alternative position is fundamentally flawed.

This is not to say that I cannot appreciate the arguments, the motivations and, to a degree, the value of arguments that presume that technology is value-free. Nevertheless, I cannot take them as seriously as work conducted from what I consider to be the more defensible perspective. Given that Parens is not proposing binocularity as a ‘grand, meta-lens’ (p.9), ‘cure or solution’ (p.10), or ‘panacea’ (p.172) perhaps this is all that is required when oscillating between competing, contradictory and incommensurable points of view. If so, one could think that what Parens is proposing is a mode or style of interaction between those with differing ethical stances and perspectives. Whilst he is not suggesting we abandon the pursuit of singular or monocular ethical perspectives, arguments and accounts, he is questioning how we ought to conduct ourselves when speaking across such divisions. One might, then, take him to be offering an ethics of the public square or, to put it another way, attempting to find a common socio-political space from which we can give proper consideration to divergent but genuinely held ethical perspectives. As such ‘binocularity’ is a kind of political stance, built upon the recognition that the neutrality of liberalism is not the same as liberalism being value free (p.49).

Whilst it is not discussed, at least not in any detail, Parens’ approach can be seen as insisting on the value-laden nature of the public square, our political debates and, for that matter, our ethical discourse. One can, I think, see this as predicated on the assumption that applied or practical (bio)ethics is, in essence, a contemporary political technology, one that bolsters the apparent neutrality of liberalism. As such it would seem that binocularity is predicated on the assumption that human technologies are not value-free, but inherently value-laden. Binocularity is, then, something that conforms to the worldview of the critics. However, it is not clear how well it might sit with those enthusiasts who cleave to the notion that technology is, or can be, value-free and that ethics is, or can be, considered in an ‘objective’ matter to be pursued through adopting an ‘impartial’ stance (p.23). If my analysis is well-founded, it is not clear to me why Parens’ putative opponents, the enthusiasts, would think the binocular approach worth considering; it seems to be founded on a set of values that seem anathema to their favoured approach.

In the chapter ‘Closing Thoughts’ Parens details how, when he embarked on his first major project at the Hastings Centre, he adopted a ‘high reason’ approach to (bio)ethical analysis of enhancement and did so against his own academic training and intellectual inclinations (p.161). Given that Parens identifies with the critics’ camp, one can see this as an attempt to adopt the stance of his opponents, the enthusiasts. Whether this was done to prove them wrong on their own terms or, as is more likely, something that naturally resulted from the process of entering a new field, of being a newcomer who naturally tries to fit in and find his feet by conforming to the rules of the disciplinary game, is not relevant. What matters is that the approach adopted by Parens belonged to his opponents. Whilst one cannot fault him for it – it was through doing so that Parens was able to fully develop his own ethical stance – it is nevertheless illuminating. In this light one might consider if Parens’ metaphor of binocularity fails to fully challenge his opponents; if, despite his intentions, it cedes too much ground to the enthusiasts thereby allowing their style of monocular ethics to flourish and, ultimately, maintain its position of dominance.

Against this one can, I think, point to an underdeveloped aspect of Parens’ account. On the one hand he claims binocularity runs against the grain of “the first law of thinking dynamics” (p.40), as conducting intellectual enquiries using more than one lens requires more effort than monocular thinking. However, towards the end of the book, Parens discusses a couple of cases that reveal the way in which ordinary individuals often appear to be thinking in a binocular manner and, furthermore, seem to be doing so with relative ease (p.149-151). If this is the case it seems to belie the notion that “we can’t actually think with any two lenses at once” (p.39). As the notion of lens is, here, a metaphor for ‘conceptual framework’ we should, I think, acknowledge that monocularity is a product of thinking from within specific disciplinary perspectives and may not be something that troubles everyday human reflection, at least not to the same degree.

To be clear, monocular disciplinarily has served us well. Nevertheless, given that the notion of ethical expertise or, at least, moral authority is widely rejected, then we should consider the positive and negative consequences that disciplinary rigour in the field of ethics has had for the way we understand our ordinary or everyday ethical thinking. Read as a plea to further reconnect academic ethics, and the study of meaning questions more generally (p.4), with lived experience as – for example, those working in feminist and disability ethics have done – and a broader, humanities based, understanding of human being, Parens’ argument takes on greater significance; it indicates that further reflexive development of this field of enquiry is possible. Indeed, consistent with this thought, Parens suggests that we are at the beginning of a ‘second wave’ in enhancement debates, one that exhibits a greater degree of binocularity (p.9 & 175). If what Parens calls the second wave is, as I suspect, marked by a relatively sophisticated and interdisciplinary approach to bioethical analysis, then his binocular habit of thinking may offer a much needed guide as to how such scholarship might be collectively understood and, ultimately, pursued in such a way as to contribute to and participate in the common good or, in Parens terms, human flourishing in the broadest sense.

 

 

 

 

 

Call for Papers – special issue of the Journal of Bioethical Inquiry

4 Nov, 15 | by cquigley

 

The editors of a forthcoming (2017) special issue of the Journal of Bioethical Inquiry on “Investigating public trust in expert knowledge: ethics, narrative and engagement” are currently inviting submission of papers.

The special issue will be the first of its kind to examine the ethics of public trust in expert knowledge systems in emergent and complex global societies. Through an interdisciplinary approach, it will draw from contributions in bioethics, the social sciences and the medical humanities.

Guest Editors: Silvia Camporesi (King’s College London), Mark Davis (Monash University), Maria Vaccarella (University of Bristol)

Trust pervades personal, social and political life. Basic trust is seen as the foundation of self, trust figures in the everyday reciprocity of social relations, and governmentality is imbued with questions of trust and distrust. Trust in expert knowledge (i.e. willingness to believe, endorse and enact expert advice) has emerged as a problem for governments seeking to engage and influence publics on matters as wide-ranging as public policy on the environment and economic development, biopolitics, and wellbeing over the life course. The knowledge systems which support climate change policy have been criticized and even refuted, leading to public policy challenges for action on climate. The uptake of vaccines in populations appears to be eroding and scientific/ethical controversies have marked the field. The emerging ‘superbugs’ crisis requires that publics engage with the idea that antimicrobials are no longer available to the extent they once were. Biotechnological interventions in reproductive life and health are subject to changed expectations for expert and consumer rights and responsibilities. The recent explosion of the CRISPR genome editing debate has brought with it socio-technical expectations (e.g. CRISPR technologies as a panacea for a world rid of diseases from birth, and some say even of ageing), together with fears of eugenics and a return to the discourse of designer babies, which now seem a possibility. Public life is marked also by the questions of trust, knowledge and ethics implicated in end-of-life decision making, related controversy over physician-assisted suicide and other questions of life’s limits. Against this backdrop of troubled trust, expert knowledge and changing bio/ thanopolitics, how can governments engage publics? How do public communications take effect? How do experts and publics narrate trust? What are the ethical ramifications of efforts to garner, sustain or regain public trust? As some have argued, are we already post-trust and therefore in alternative modes of public engagement with the idea of collective life?

Topics

Contributions are solicited from the above disciplines that look at the role of narratives in the construction and deconstruction of public trust in expert knowledge and at ethical or unethical ways of engaging with the publics on a variety of topics, including but not limited to:

  • sustainability and climate change
  • public policy and economic development
  • vaccination and other biotechnologies
  • emerging infectious diseases, including superbugs
  • reproductive health
  • provider-consumer relations in health care and beyond
  • genetics, including genome editing technologies (e.g. CRISPR/Cas9)
  • race
  • end-of-life decision making

Methodologies:

We seek contributions that apply narrative approaches to bioethics, sociology, and medical humanities.

The special issue will consist of 8-10 contributions that employ a variety of methodological approaches for a recommended length of 7,000-7,500 words each.

Instructions for authors for submission to JBI can be found here:

http://bioethicalinquiry.com/wp-content/uploads/JBI_IFA.pdf

Abstract Submission and Timeline

Extended abstract of 750 words should be submitted to Dr Silvia Camporesi by January 25, 2016. Please clearly state in your abstract the methodology you are employing in your paper, and how your contribution addresses the topic of the special issue ‘‘Investigating public trust in expert knowledge: ethics, narrative and engagement’.

A decision on the abstract will be notified by Feb 15, 2016.

Full papers are expected by May 1, 2016.

Reviewed papers will be returned to authors by August 1, 2016.

Revised papers are expected by October 1, 2016.

The special issue is expected to appear in print in June 2017.

For inquiries contact Dr Silvia Camporesi: silvia.1.camporesi@kcl.ac.uk

 

Who are we as Doctors? Why an exploration of our significance can lead to better care by Benjamin Janaway

27 Nov, 14 | by BMJ

Recently I lost a patient. A lady in her 60’s whose hand I held for months and who’s passing will stand as a turning point in my career.

Having spent several months working in oncology my view of the role of a doctor has been tested time and time again. Publically observed heuristics of the role of doctors, portrayed subjectively in television and film, novels and novellas, are the hippocratically charged and dutiful healers. Both a font of knowledge and diary of experience, the doctor is seen as a paternalistic figure and eternal purveyor of the omnipotent band aid.

In some cases, within primary care and acute medicine, this may indeed be the case. Early recognition of pathological processes expressed through familiar clinical paradigms allows for rapid reversal of such malady, leading to objective improvement of the patient and maintenance of this social perception. However my experience of secondary and tertiary care of patients with chronic conditions tells a different story.

These patients, when viewed holistically as both the sum of their experience and the filtered view of our own experience, take on significance both within day to day clinical care and the greater role of disease in their lives. Identification with disease, as I have previously mentioned, is a natural and almost unavoidable consequence of the maladaptive nature of the human mind. Our natural insecurities, developed arguably within Jungian theory to inspire adaptive development, can be argued to be destructive when applied to modern day context.

The presence of disease is not just an event in a person’s life, but an event with added context and personally subjective significance. For example, a broken hand means more to a pianist than a footballer. The subjective significance of a change in health status can be explained by the patient’s reliance on past experience and their perceived importance of such a change within the context of their entire lives. The identification of their lives with the change is what the patient sees, but the objective measurement taken by clinicians is usually less in depth.

In terms of cancer, this identification can be both freeing and incarcerating. I have worked with a number of patients, young, old, religious or atheistic with a number of different cancers of varying aggression. Some of these patients were at the start of a journey with an indefinite end, and some were at the end of a journey of indefinite meaning. For some, the end of a long fight, although sad, had changed their lives dramatically and they had lived more in a short time than they had in their lives.

My own grandfather had been diagnosed with multiple myeloma a few years ago and passed away earlier this year. Being both his grandson and a doctor in training was a balancing act, knowing more about the practical and prognostic side of his care and tempering my expectations with that of him and my family. I found this process infinitely difficult and adaptive, learning from my emotional responses better ways to address his own needs and questions.

I would like to say that one of the many lessons I learned from him is that a stoic disposition and optimistic attitude in the face of uncertainty is a great strength. Life goes on between our plans, and our aspirations and reality do not necessarily correlate and it is up to us to meet these changes head on, learn what we can and move on the future. In the treatment of cancer, and the management of my patients, this stoic and optimistic attitude, balanced with an understanding of the patients own identification and experience of disease, is most useful.

So when we consider our own significance within the patient’s experience we must remember the paternalistic view of the omnipotent healer, but also realise that we play only a part in the production of their lives. We are second to the protagonist, and must realise the overall significance of our words on actions not just on the objective clinical state of the patient, but the holistic sphere of their entire disease experience.

More and more I have realised my role as a junior physician and frontline carer is to support the expectations of the patient within a realistic schema. To attempt to best understand their view, but present it to them within a spectrum of experience based on my continued learning and reflection. The omnipotent heuristic can therefore be argued to be of less importance than the archetypal omnibenevolent. As doctors our roles are to first understand the patient and their own judgement of disease significance, and tailor our treatment and interaction in an empathetic and individualised way.

We try to act in the patients best interests, and that means not only to address the physical aspects of their disease but the entire holistic side. Within oncology, this idea takes on extreme importance, as often the societal view of cancer and its ultimate path takes hold in a patients mind. For some it is a challenge, for some freeing, and for others a less positive conclusion. Whatever the view taken, it is up to us as doctors to realise our lines in the script of the patient’s life when this plot twist comes.

For my lady, and for my grandfather, the advent of their disease granted them a new perspective and through long discussion with both I realised the beauty of a new view. Their priorities and expectations changed and they lived without fear. This realisation painted my day to day communication with both and I would hope played a part in making the last years of their lives not just bearable, but an experience they could learn from and leave their mark on the world.

For me, their mark is on my heart, a sign saying ‘Listen and stay open’.

The opinions expressed in this article are those of the author and may not represent those of SDHCT. No patient identifiable information is included.

Correspondence: Dr BM Janaway, Flat 4, Castle Chambers, 147 Union Street, Torquay, Devon TQ1 4BT

Review: “Contested Spaces: Abortion Clinics, Women’s Shelters and Hospitals.”

28 Apr, 14 | by gbelam

We have another great review today, of Lori A Brown’s book “Contested Spaces: Abortion Clinics, Women’s Shelters and Hospitals.” It’s by Sophie Jones of Birkbeck College, University of London, and considers aspects of architecture, landscape & design, and wider ideas about feminism and attitudes to women’s health in the USA.  Looks like a fascinating area for discussion. 

– Georgia Belam

 

Review: “Contested Spaces: abortion clinics, women’s shelters and hospitals.” by Lori A Brown

By Sophie Jones

 

‘Is it possible to build non-sexist neighborhoods and design non-sexist cities? What would they be like?’[1] Posing these questions in 1980, Dolores Hayden vocalized the utopian impulse of feminist architecture. A generation of women architects were convinced that Hayden’s question had an affirmative answer. Their plans for housing complexes with integrated childcare centres and cooperatively-run kitchens were not merely isolated amendments to the world as they knew it, but blueprints for a materialist feminist revolution. In Contested Spaces: Abortion Clinics, Women’s Shelters and Hospitals, Lori A. Brown brings this heritage of feminist architecture to bear on contemporary approaches to these charged sites. Brown asserts, ‘Space matters. Space is at stake. Control over geography is being legislated by those who want to eliminate a woman’s right for reproductive choice.’[2] Her proposals, which include bullet-resistant windows and abortion clinics in shopping malls, bespeak a different political climate: these are constrained negotiations, not revolutionary demands.

 

Brown’s research into the spatial politics of abortion clinics—and, to a lesser extent, women’s shelters and hospitals—is primarily focused on the United States, with some comparative analysis of Canada and Mexico. The author, an architect based at Syracuse School of Architecture, announces her project as a dual intervention, correcting her discipline’s lack of social engagement while drawing public attention to the feminist politics of the built environment. Debates about abortion often prioritise the subject of time, dwelling on the abstract question of when the foetus acquires a right to life. Contested Spaces marks a welcome turn to the spatial, as growing numbers of women across North America face harassment outside clinic doors, if and when they manage the long, expensive journey to their nearest abortion provider. Brown has transformed these hostile landscapes into diagrams punctuated by sobering statistics. On one map, a stark black line represents a 404 mile journey across South Dakota to the only clinic in Sioux Falls—a route served by no public transportation.

 

The book, which Brown positions ‘somewhere between theory and practice’, is concerned not only with the siting, accessibility and security of buildings, but also with the way architecture manifests social antagonisms.[3] This approach makes sense, but the abrupt shifts between registers are telling. A section about Dr. George Tiller, the Kansas abortion provider shot to death by a terrorist in 2009, segues awkwardly into a recommendation that clinics install meditation rooms for quiet reflection. The story of Paulina del Carmen Ramírez Jacinto, who was refused an abortion at the age of 13 after being raped during a break-in at her family home in Baja California, is followed by a consideration of the importance of lighting and paint choices in reproductive healthcare facilities. Noting the disjunction here is not a matter of policing the boundary between the serious and the trivial. Rather, it is to pay attention to the conditions that interrupt feminist blueprints for the future before they become reality.

 

Women, as Contested Spaces demonstrates, have historically found ways to repurpose structures designed to enclose them. In the 1960s and early 1970s, California’s Army of Three and Chicago’s Jane Collective helped women to access ‘menstrual extraction’ procedures, often in domestic spaces. Brown notes that, for these underground collectives, ‘Domestic space became the space of choice, liberation, security and safety from the law.’[4] Meanwhile, the Netherlands-based initiative Women on Waves dodges national abortion laws by providing terminations at sea. As Brown astutely observes: ‘Connected with neoliberal policies, this project exploits the idea of free trade zones and International waters and exists because it plays against hegemony’s own system through legal loopholes of globalization.’[5] A similar intervention occurred recently in South Dakota when, faced with a prospective ban on almost all abortions, Cecilia Fire Thunder proposed opening a clinic on her reservation, which was beyond federal jurisdiction. In mapping the coordinates of a world without punitive borders, these projects testify to the potential scope of feminist spatial theory.

 

Yet the visions for feminist space projected by past generations of abortion rights activists seem woefully truncated by contemporary compromises. Among these are the ‘bubble laws’ adopted in some US states, which institute ‘zones of protection’ around clinics and the patients entering them. For Brown, the difficulty of enforcing these laws lends their name an ironic resonance: the translucency and fragility of bubbles mirrors the precarious status of abortion access. Her interviews with private clinics in the most restrictive US states—which include Mississippi, South Dakota, and Utah—uncover inventive tactics for grappling with government pressure and anti-abortion hostility. Clinics have developed an impressive repertoire of strategies for combating the harassment of their patients: installing sprinkler systems outside clinics, scheduling landscaping work to spray demonstrators with grass, and setting up speakers to drown out protest noise with music.

 

With the battle lines drawn, the project of drawing up blueprints for revolutionary feminist health spaces appears simultaneously urgent and remote. Few clinics have the freedom to choose their location because many landlords refuse to let space to abortion providers. Meanwhile, renovation proposals attract excessive levels of scrutiny from public officials beholden to the anti-choice movement. Is it better to be a free-standing clinic, with the autonomy to install tight security at entrances and exits, or to be absorbed into a multi-unit complex, where patients and workers have more anonymity? When making design decisions such as these, providers feel trapped between a rock and a hard place.

 

Brown writes, ‘Reproductive healthcare facilities have become twenty-first century equivalents to medieval cities where walls and moats were once used for security from intruders.’[6] There is, perhaps, an alternative to this state of enclosure. One of the clinic directors told Brown that abortion needs to become part of a larger movement for social justice, linked to campaigns for childcare, education, and health. This is the insight of the reproductive justice movement, instigated by women of colour in the US who have drawn attention to the problems of isolating abortion as a single issue.[7]

 

Contested Spaces opens with a synoptic journey through feminist geography and architectural theory, taking in Nancy Fraser on subaltern counterpublics, Iris Marion Young on pregnant embodiment, Homi Bhabha’s notion of a third space, and Elizabeth Grosz on the mutual constitution of bodies and cities. In her conclusion, however, Brown risks collapsing this nuanced discussion of space into a question of location. She writes:

 

I advocate for clinics to become more centrally located in our daily spatial lives. They need to be front and center in our society, not hidden away and difficult to access. Locate them in shopping malls where protests cannot happen due to malls not being public space.[8]

 

Brown goes on to argue that terminations should be provided not only in mainstream hospitals but in shopping malls, military bases, jails, prisons, high schools and churches. Grouping these institutions together as elements of our ‘daily spatial lives’ evades the important distinctions between their modes of funding and management. It is odd that Brown does not consider the stake shopping mall abortion clinics might have in a privatised healthcare system, given the centrality of abortion to debates over the Obama administration’s Affordable Care Act. Meanwhile, the nuances of reproductive healthcare in prison are ill-served by the proposal for jail-based abortion clinics, particularly in the wake of revelations that California prisons subjected female inmates to forced sterilisation as recently as 2010. A tension between pragmatism and utopianism animates Contested Cities, and its conclusion appears to decide in favour of the former. Meanwhile, Hayden’s challenge – ‘What would a non-sexist city look like?’ – reverberates, as a reminder of way the architecture of reproductive justice can be integrated into a broader vision for social change.

 

 

[1] Dolores Hayden, ‘What Would a Non-Sexist City Be Like? Speculations on Housing, Urban Design, and Human Work’, Signs, Vol. 5, No. 3, S170-S187.

[2] Lori A. Brown, Contested Spaces: Abortion Clinics, Women’s Shelters and Hospitals (Farnham: Ashgate, 2013), p. 101.

[3] Contested Spaces, p. 37.

[4] Contested Spaces, p. 78.

[5] Contested Spaces, p. 82.

[6] Contested Spaces, p. 185.

[7] See http://www.sistersong.net/index.php?option=com_content&view=article&id=141&Itemid=81

[8] Contested Spaces, p.

Ayesha Ahmad: Review of ‘Able-Bodied – Scenes from a curious life’ by Professor Leslie Swartz

26 Feb, 13 | by Ayesha Ahmad

 

Having had the privilege to meet with Professor Swartz, I read his most recent book publication, ‘Able-Bodied – Scenes from a curious life’ with the jovial sounds of his uncanny ability to reflect on human nature and experiences in the background.

 

I certainly found Professor Swartz’ presence evident in the somewhat apologetic way he introduces and describes his family, as if telling a story and telling a secret amount to a similar thing. Yet, his words behold a compassion and gentleness that even the greatest of sentiments often fail to display.

 

more…

Ayesha Ahmad: Review of ‘Doing Clinical Ethics’ by Dr Daniel Sokol

4 Dec, 11 | by Ayesha Ahmad

Since Hippocrates in early 5 B.C., Medicine has carried an ‘angel on its shoulder’; a reflexive gaze on the skill, and phenomenologies of healing between the doctor and his patient. Ethics is a code, a practice, and a guide amid the terrain of the hands that tend to the body using instruments of medicine’s enterprise. Referring to the Oath:

I will preserve the purity of my life and my arts’.

Daniel Sokol, Honorary Senior Lecturer at Imperial College, London and recently qualified barrister, undertook the challenge of fitting ‘ethics’ into our contemporary medical practice; whereby Medicine is confronted by a body unprecedented in relation to the ways in which we can perceive, examine, intervene, create, and prolong the existence of our bodies; our lives.

more…

Khalid Ali: Film Review: Asmaa: Directed by Amr Salama: Star rating ****

3 Nov, 11 | by Deborah Kirklin

With annual World AIDS Day taking place 1 December, this new Egyptian film, which was shown at the recent London Film Festival, is very topical.

The subject of HIV in European and American cinema has of course been explored in many films (such as “Savage nights” (1992), “Philadelphia” (1993), “The Hours” (2002), and “Angels in America” (2003)). However depictions of HIV positive characters in Arab cinema have been scarce, characteristically portraying HIV patients as promiscuous sinners who deserve to be ill, or else as victims of an American conspiracy to spread HIV infection amongst young people in the Arab world. more…

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